Wednesday, December 8, 2010

Academics Diligently Toe the Party Line

In addition to the sexualization of HIV, which yesterday's blog post was about, there is also the rather childish reflex which amounts to 'all men are violent, all women are victims'. There may be some truth in the reflex, that's not my objection. But it isn't very helpful in the HIV prevention field to assume that the virus is mainly spread by men in high prevalence countries. It isn't now and it never was.

An article notes: "The expectation that men rather than women are the index cases has been widely promoted by evidence of low condom use by men, a greater burden of sexually transmitted infections, male dominance in sex-related negotiations, greater number of sexual partners (including polygamous marriages), more frequent alcohol misuse, and greater likelihood of transactional (when a client exchanges money or gifts for sex) or intergenerational sex."

Of course, if HIV is not solely, perhaps not even primarily driven by sex, the assumption that it is driven by men becomes equally untenable. But even if HIV is primarily driven by sex, there has never been any clear support for the assumed role of men in playing a greater role in spreading HIV, with women being, almost always, innocent victims.

This article on discordant relationships, relationships where only one partner in a couple is HIV positive, finds that the woman is just as likely as the man to be the 'index case', the one infected (or the first one in the relationship to be infected). That has been recognized in the past but this paper collects together a number of studies involving thousands of participants.

In Kenya and Uganda, modes of transmission studies have shown that some of the most at risk people are those in long term, monogamous, heterosexual relationships, such as married people. Despite this, the term 'most at risk' has been reserved for men who have sex with men, commercial sex workers and intravenous drug users.

In spite of identifying these last three groups as being at high risk of HIV infection, very little money or programming has been used to target them in prevention programs. And in spite of the fact that HIV is clearly spreading inside stable relationships, programming has generally concentrated on advising people to avoid sex outside of such relationships.

You could say that the HIV prevention strategy has been, and continues to be, to advise people who are probably not engaging in unsafe sex to avoid unsafe sex. And the strategy simply ignores those who are probably at high risk of becoming infected. They are not completely ignored, but these groups receive very little attention, funding or viable prevention programs. This strategy hasn't changed much, despite 20 years of research.

HIV prevention programming has concentrated on a lot of finger-wagging about sex and 'unsafe' sex, when it has long been clear that sex, unsafe or otherwise, is unlikely to be involved in a substantial proportion of HIV transmission in the highest prevalence countries. Little or nothing has been said about non-sexually transmitted HIV.

Findings about discordant couples never seem to have set off alarm bells, even though many people in such relationships have claimed to only have had sex with their partner or to have taken precautions against HIV, unplanned pregnancy and sexually transmitted infections. In some couples where both partners were infected, they were infected by different strains of HIV.

Such evidence that HIV may not always have been transmitted sexually was sometimes interpreted as evidence that women can be promiscuous too. And it was sometimes even presented, uninterpreted, as if there is a great mystery to HIV transmission that is not related to sexual behavior.

The possibility of non-sexual transmission playing a part is briefly considered before being summarily dismissed. Perhaps the authors, Oghenowede Eyawo, Damien de Walque, Nathan Ford, Gloria Gakii, Richard T Lester, and Edward J Mills, are more concerned what their peers might think if they were to challenge the view that all Africans are promiscuous, irresponsible, ignorant and many other things that form the mainstream view of HIV in Africa.


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